Balloon Enteroscopy Research Articles

Use of texture and color enhancement imaging to identify the pancreatic duct orifice in a patient with a pancreaticojejunal anastomotic stricture.

An endoscopic approach to pancreaticojejunal anastomotic stricture (PJAS) using a balloon enteroscope in patients who have undergone pancreaticoduodenectomy is challenging [1] [2] [3]. Identification of the pancreatic duct orifice is often difficult because of complete PJAS. Herein, we report the case of a patient with a PJAS in whom a texture and color enhancement imaging (TXI)-equipped new-generation endoscopy system (EVIS X1; Olympus Medical Systems, Japan) [4] was used, which facilitated identification of the pancreatic duct orifice.

Endoscopic diagnosis and treatment of patient with early cardioesophageal cancer three months after gastric bypass surgery

Problems of obesity and its accompanying metabolic disorders remain relevant throughout the world and are due to an increased risk of disability and early mortality in patients with this pathology. Currently, bariatric surgery is recognized as the most effective treatment for morbid obesity. Of exceptional importance are not only the technical features of operation, but also a full preoperative examination. The occurrence of gastric cancer after bariatric surgery is a rare but occurring phenomenon, often associated with insufficient quality of preoperative endoscopic examination. We presented a clinical case of endoscopic diagnosis and removal of early cardioesophageal cancer in a patient with morbid obesity, three months after mini-gastric bypass surgery, as well as examine bypassed stomach with single- balloon enteroscope.

S1583 Surveillance With Double Balloon Enteroscopy in Adult Patients With Peutz-Jeghers Syndrome: A Single Center Experience

Introduction: Peutz-Jeghers syndrome (PJS) is an inherited polyposis syndrome caused by mutation in the STK11 gene, and characterized by hamartomatous polyps throughout the gastrointestinal tract, most often in the small bowel (60-90%) and colon (50-64%). Presenting symptoms in PJS are often related to symptomatic polyps, including intestinal obstruction, abdominal pain, and bloody stools. For PJS patients, current recommendations support screening upper endoscopy, colonoscopy, and video capsule endoscopy at age 8-10, and if no polyps identified then again at age 18. Small bowel screening is recommended every 2-3 years. Deep enteroscopy, via antegrade or retrograde balloon enteroscopy, is often required for clearance of larger polyps visualized on video capsule endoscopy (VCE). The optimal follow-up strategy and modality of screening and surveillance of small bowel polyps is controversial. We aimed to evaluate if proactively performing deep enteroscopy vs serial VCE in adult PJS patients reduces risk of requiring subsequent surgical intervention. Methods: We retrospectively collected data from adult patients over 18 years of age with Peutz-Jeghers syndrome who underwent deep balloon enteroscopy for small bowel surveillance. Patients within this subset underwent proactive screening with antegrade double balloon enteroscopy performed approximately every one to 2 years. Data collected included number of prior small bowel surgeries before onset of and during deep enteroscopy surveillance, and complications. Results: Thirteen patients underwent deep enteroscopy from 2010 through 2021. Average number of prior small bowel surgeries was 1.9 (SD 1.4), average number of balloon enteroscopies during surveillance period 2.8 (SD 1.4), and average number of surgeries during balloon enteroscopy surveillance 0.46 (SD 0.66). There was a significant difference between number of surgeries before and during surveillance period (P=0.002). Conclusion: The initial standard screening modality for small bowel polyps and malignancy, VCE, can be complicated by increased risk of capsule retention given likelihood of prior surgery and possibility of obstructing polyps. Additionally, within the PJS cohort, there is a high yield for pathology which may ultimately require therapeutic deep enteroscopy anyhow. Our study, though small, does indicate that on a proactive balloon enteroscopy surveillance protocol there is a significantly lower risk of requiring small bowel surgery.

S2004 Colonic Varices as a Complication of Pancreatic Adenocarcinoma: A Case Report and Literature Review

Introduction: Colonic varices are a rare subtype of ectopic varices with unknown prevalence rates, likely due to under-diagnosis. They form due to venous anomalies, portal hypertension, splenic or portal vein (PV) thrombosis and mesenteric vein obstruction. We present a rare case of isolated colonic varices related to pancreatic cancer. Case Description/Methods: A 64-year-old male with pancreatic cancer presented with hematochezia. Endoscopic evaluation at an outside facility showed fresh blood in the colon and terminal ileum. His hemoglobin dropped from 13 to 6 mg/dL and a tagged RBC scan identified extravasation in the right lower quadrant, localizing to the ileum. He was transferred to our hospital for a retrograde single balloon enteroscopy, which noted isolated ascending colon and hepatic flexure varices (felt to be the source of bleeding) and normal ileum. A CT angiogram revealed the pancreas mass encased the celiac axis, superior mesenteric artery, and portal confluence with occlusion of the superior mesenteric vein (SMV) and extensive collateral vessels in the hepatic flexure/ascending colon. Interventional radiology and surgical oncology were consulted for management. Given extensive vasculature involvement, no interventions were possible, and patient was medically managed. Discussion: Pancreatic cancer is a cause of left sided portal hypertension through occlusion of either the splenic vein or a non-splenic vein branch of the PV. Isolated colonic varices secondary to pancreatic cancer are rarely described. The gold standard for diagnosis is CT or selective mesenteric angiography. Often, they are diagnosed by colonoscopy for lower GI bleed evaluation but can be missed due to flattening with insufflation or blood precluding visualization. Treatment options are limited and mostly based on recommendations from case reports as there are no guidelines. For uncomplicated cases, conservative management with laxatives and iron supplementation is reasonable. For SMV occlusion, stenting of the SMV can reduce PH (table 1). In active bleeding, options include embolization, endoscopic therapy (sclerotherapy, cyanoacrylate injection, argon plasma coagulation, and band ligation), or transjugular intrahepatic portosystemic shunt (TIPS). However, if significant bleeding, laparoscopic ligation or colectomy may be indicated. Management of colonic varices due to pancreatic malignancy remains controversial and may require a multidisciplinary approach.

S660 Algorithmic Approach to GI Bleed Using Video Capsule Endoscopy Prior to Double Balloon Enteroscopy Is Associated With Higher Therapeutic Yield and Decreased Readmission at a Tertiary Medical Center

S660 Algorithmic Approach to GI Bleed Using Video Capsule Endoscopy Prior to Double Balloon Enteroscopy Is Associated With Higher Therapeutic Yield and Decreased Readmission at a Tertiary Medical Center

S2544 Acute Symptomatic Hyponatremia Following Single Balloon Enteroscopy With Water Immersion: Be on the Lookout

Introduction: The water immersion endoscopic method is a safe and often used endoscopic technique. We report a unique case of electrolyte abnormalities in a single balloon enteroscopy secondary to this procedure Case Description/Methods: A 70-year-old female with HTN and hypothyroidism presented for single balloon enteroscopy for removal of a retained capsule. The capsule was initially performed for the of work up of melena and iron deficiency anemia after a negative upper endoscopy and colonoscopy. Physical exam and labs prior to the procedure were normal, including a sodium level of 139. The patient underwent the planned enteroscopy with water emersion with an estimated amount of 4 L of water being used. Shortly after completion of the procedure, the patient was noted to be delirious and have an altered mental status. The patient became aphasic, began clenching her fists, and was shaking. A sodium level post-procedure was obtained and was 113. A head CT scan was performed and no central involvement was noted. The patient was managed with 3% hypertonic saline and her symptoms resolved. Over the next 2 days patient’s sodium level normalized and the patient was discharged from the hospital. Discussion: This is the first reported case of hyponatremia secondary to water immersion endoscopy. While there is an abundance of reports describing hyponatremia in urologic and gynecologic procedures those procedures generally use glycine and mannitol as their irrigate. With regards to GI procedures, hyponatremia secondary to polyethylene glycol-electrolyte preparation has infrequently been reported. Free water irrigation/immersion is generally regarded as safe during gastroenterological procedures. Our case, brings awareness to the possibility of symptomatic hyponatremia following prolonged enteroscopy with the use of large volume water irrigation/immersion. Absorption of ingested water and most solutes occur in the proximal small intestine. If a large amount of fluids are necessary then normal saline can be utilized instead of water. Limiting water to 1.5 liters and suctioning excess water can help minimize these complications. Clinicians should be aware of this serious complication when performing these procedures.

S657 Risk of GI Bleed Recurrence in Dual Antiplatelet Therapy Compared to Antiplatelet Monotherapy in Patients Who Underwent Double Balloon Enteroscopy at a Tertiary Care Center

S657 Risk of GI Bleed Recurrence in Dual Antiplatelet Therapy Compared to Antiplatelet Monotherapy in Patients Who Underwent Double Balloon Enteroscopy at a Tertiary Care Center

S1097 Clinical Outcomes of Double Balloon Enteroscopy: An 8-Year Tertiary Center Experience

Introduction: The objectives of this study are to examine clinical characteristics of patients undergoing anterograde and retrograde double balloon enteroscopy (DBE) and to assess factors predicting 6-month readmission Methods: We conducted a retrospective cohort study of patients (n=1162) who underwent DBE at an academic tertiary care center between November to December 2020. Baseline patient data as well as DBE related variables were collected. Outcome variables included readmission rates, diagnostic and therapeutic yield. Measures of central tendency and frequency distributions were used for univariate analysis. Chi-square and student 2 sample t-test were performed to compare patient characteristics. Logistic regression was used for outcome variable analysis. Results: Of the 1162 DBE procedures, 50.95% were male (n= 592) with a mean age of 61.29 (15.33, SD). The most common indications for procedure being GI bleed (61%) and abnormal video capsule endoscopy findings (30%). The cohort’s rate of positive diagnostic yield was 65% and 57% for therapeutic yield. The mean procedural time was 39.80 (21.31, SD) minutes, and 77% of DBE patients received anterograde procedures. Compared to retrograde procedures, a higher proportion of DBE patients with anterograde procedures had positive diagnostic yield (66% vs. 62%, p=.254) (Table). Readmission rates at 30 days and 6 months were 11% and 18% respectively. Anterograde procedures were more likely to be inpatient (37% vs 29%, p=0.018) and associated with shorter procedure time (38.67 ± 204.5 vs 43.7 ± 23.7 minutes, p=0.0008) and higher therapeutic yield (60% vs 46%, p=0.00) ( Figure). Univariate analysis depicted inpatient status, total procedure minutes, and anticoagulation use to be associated with 6-month readmission (all P< 0.05). After controlling for each variable through multivariable analysis, inpatient status [OR:3.56, 95% CI (2.59-4.89), p=0.00] and total procedure minutes [OR:1.01, 95% CI (1.00-1.01), p=0.03] remained significant predictors of 6-month readmission Conclusion: DBE procedures has high efficacy for both diagnostic and therapeutic yield while evaluating GI bleed, abdominal pain, iron deficiency anemia, as well as performing ERCP in patients with altered upper GI anatomy. Patients undergoing anterograde DBE are associated with shorter procedure time and higher therapeutic yield compared to patients undergoing retrograde DBE. DBE patients who are inpatients and higher procedural times are more likely to be readmitted in 6 months.Figure 1.: Univariate and Multivariable Logistic Regression Analysis predicting 6-month readmission rate Table 1. - Patient characteristics and outcome variables stratified based on procedure type (anterograde vs retrograde) Variable Anterograde (n=900) Retrograde(n=262) P-Value Sex Male 459 (51%) 133 (51%) .95 Female 441 (49%) 129 (49%) Age, Range: 35-93, Mean (SD) 61.17 (15.30) 61.69 (15.49) .629 Patient Type Outpatient 571 (63%) 187 (71%) .018 Inpatient 329 (37%) 75 (29%) BMI Less than 25 304 (34%) 77 (29%) .183 25 or more 596 (66%) 185 (71%) Altered Anatomy No 695 (77%) 234 (89%) .000 Yes 205 (23%) 28 (11%) Anticoagulation No 780 (87%) 230 (88%) .636 Yes 120 (13%) 32 (12%) ESRD No 858 (95%) 247 (94%) .485 Yes 42 (5%) 15 (6%) Anesthesia Type General 809 (90%) 97 (37%) .000 Mac 91 (10%) 165 (63%) Total procedural time Mean (SD) 38.67 (20.45) 43.70 (23.70) .0008 Therapeutic Yield No 361 (40%) 141 (54%) .000 Yes 539 (60%) 121 (46%) Positive Finding No 305 (34%) 99 (38%) .244 Yes 595 (66%) 163 (62%) Readmission 30-day No 791 (88%) 238 (91%) .187 Yes 109 (12%) 24 (9%) Readmission 6 Month No 731 (81%) 219 (84%) .383 Yes 169 (19%) 43 (16%)

S3478 Successful Diagnosis and Treatment of Radiation Enteropathy With Single Balloon Enteroscopy and Hyperbaric Oxygen: A Case Report

Introduction: Radiation enteropathy (RE) is a major complication of radiotherapy treatment for patients with abdominal and pelvic malignancies. Intestinal damage is due to disruption of angiogenesis, leading to capillary fibrosis and bowel ischemia. These pathologic changes can present clinically as small bowel obstruction from luminal stenosis or obscure GI bleeding (undiagnosed after upper endoscopy (EGD) and colonoscopy), which represents 5% of all GI bleeding and is typically found in the small intestine. However, endoscopy of the small bowel is challenging given its length. Deep enteroscopy via balloon assisted enteroscopy (BAE) is a valuable tool that permits exploration of the small bowel, especially given the risks associated with capsule endoscopy (CE) in patients with suspected RE. This case highlights the utility of BAE in diagnosing RE, and such awareness could improve the diagnostic timeline of patients who present with similar symptoms after undergoing abdominal radiation. Case Description/Methods: A 78-year-old male with diffuse large B-cell lymphoma involving the small bowel, underwent consolidation radiation of the abdomen. He was later hospitalized for melena and symptomatic anemia requiring transfusions. Both initial and repeat endoscopic work-up showed no evidence of active bleeding. CE was also performed and did not identify a source of bleeding. Ultimately, Single Balloon Enteroscopy (Olympus, Center Valley, PA) was pursued and revealed segmental diffuse lymphangiectasia and erythema in the distal duodenum and proximal jejunum, changes consistent with moderate to severe RE. Additionally, multiple angioectasias with oozing were appreciated and successful Argon Plasma Coagulation (Erbe Med) in focal areas was performed. Given a diagnosis of RE, the patient was referred for hyperbaric oxygen therapy (HBOT) which led to resolution of his bleeding and symptomatic improvement. (Figure) Discussion: This case was notable for its successful use of Balloon-Assisted Enteroscopy in the diagnosis and treatment of radiation enteropathy. While capsule endoscopy was utilized, it was unsuccessful in making the correct diagnosis and put the patient at risk for capsule retention. Furthermore, while many small studies have shown positive outcomes of HBOT in treating RE, it is still often underutilized. This case demonstrates the successful use of HBOT to treat RE and should be considered in patients with ongoing symptomatic anemia due to radiation injury given its favorable success rates in terminating bleeding.Figure 1.: Enteroscopic findings of segmental radiation injury in the small bowel using Single Balloon Enteroscopy.

S1833 Single Operator Cholangioscopy in a Patient With Pancreaticoduodenectomy

Introduction: Cholangioscopy in patients with surgically altered anatomy can be technically challenging. In most patients with pancreaticoduodenectomy undergoing single operator cholangioscopy, the most common approach is through a percutaneous biliary drain placed by interventional radiology. We present a case in which a modified therapeutic upper endoscope (1T scope) was used for single operator cholangioscopy in a patient with pancreaticoduodenectomy. Case Description/Methods: A 64-year-old female with Gardner syndrome requiring colectomy and classic pancreaticoduodenectomy for an ampullary adenoma 10 years prior presented for surveillance endoscopy. She previously underwent endoscopic mucosal resection and intraductal radiofrequency ablation (RFA) of adenomatous tissue at the hepaticojejunal (HJ) anastomosis. She subsequently developed a stricture at the HJ anastomosis needing sequential dilations. A 1T scope was used and advanced to the HJ anastomosis. After balloon dilation of the HJ anastomotic stricture, cholangioscopy was performed and revealed abnormal biliary mucosa (Figure) approximately 2 cm below the hilum raising concern for intraductal extension of adenomatous tissue. Cholangioscopy directed biopsies were obtained and pathology revealed tubular adenoma without high-grade dysplasia. Intraductal RFA is planned in the future. Discussion: ERCP in patients with pancreaticoduodenectomy can be challenging. Different endoscopes have been used to overcome some challenges of ERCP in altered anatomy, each offering certain advantages and limitations. Commonly used endoscopes for ERCP in patients with pancreaticoduodenectomy include the adult and pediatric colonoscopes and single balloon enteroscope. These endoscopes do not allow for performing single operator cholangioscopy due to the length of the scope or the width of the accessory channel. Our report highlights that the 1T endoscope allows for performing single operator cholangioscopy in patients with prior pancreaticoduodenectomy when the HJ anastomosis can be reached.Figure 1.: Intraductal extension of adenomatous tissue seen on cholangioscopy.

Clinical profile, diagnostic yield, and procedural outcomes of single balloon enteroscopy: A tertiary care hospital experience.

BACKGROUNDSingle balloon enteroscopy (SBE) allows ease of access for small bowel visualization and has multiple diagnostic and therapeutic indications. It provides the advantage of performing various therapeutic interventions alongside the diagnostic procedure. SBE has also been considered a relatively safe procedure with no major complications. AIMTo investigate the indications, safety, and clinical yield of SBE, and determine its effect on disease outcome.METHODSA retrospective, descriptive study was conducted at a tertiary care hospital in Karachi, Pakistan. Medical records of 56 adult patients (≥ 18 years) who underwent SBE between July 2013 and December 2021 were reviewed and data were collected using a structured proforma. A descriptive analysis of the variables was performed using Statistical Package of Social Sciences Version 19. Results are reported as the mean ± SD for quantitative variables and numbers and percentages for qualitative variables. Missing data are reported as unknown. RESULTSA total of 56 patients who underwent 61 SBE procedures were included. The mean age was 50.93 ± 16.16 years, with 53.6% of them being males. Hypertension (39.3%) and diabetes mellitus (25.0%) were the most common pre-existing comorbidities. Obscure gastrointestinal bleed (39.3%) was the most common indication for enteroscopy, followed by chronic diarrhea (19.7%) and unexplained anemia (16.4%). The majority of procedures were performed in the endoscopy suite (90.2%) under monitored anaesthesia care (93.4%). Most procedures were diagnostic (91.8%) and completed without complications (95.1%). The depth of examination ranged from 95 cm to 500 cm with a mean of 282.05 ± 90.04 cm. The most common findings were inflammation and ulcerations (29.5%), followed by masses (19.7%) and vascular malformations (14.8%). As a result of the findings, a new diagnosis was made in 47.5% of the cases and a previous one was ruled out in 24.6% of them; 65.6% of the cases had a change in management.CONCLUSIONSBE is a suitable modality for investigating diseases in the small bowel. It is shown to be technically efficient and reasonably safe and is associated with high diagnostic and therapeutic yield.

Indications and complications of balloon enteroscopy in Southwest of Iran: a 3years cross sectional survey

Introduction: The advent of capsule endoscopy (CE) and balloon-assisted Enteroscopy has changed the diagnosis and management of small intestine disorders over the past decade. The purpose of this evaluation is to review the findings of small intestine evaluation by Balloon Enteroscopy in Imam Hospital of Ahvaz between 2016 and 2019. Method: The present study is a descriptive epidemiological study that has been conducted using the files in the archives of Ahvaz Imam Hospital on a cross-sectional basis between 2016 and 2019 on all of the cases referred to this tertiary center to perform balloon Enteroscopy about their indications and any potential complication. A questionnaire containing several sections designed to collect the following data. Part A: (Basic Information) including age, sex, date and type of admission. Part B: (Record of previous diseases and procedures) including general health profile. Part C: (Enteroscopy Process Findings) and Part D: any potential complication. Results: Overall 42 procedures performed (29 male (69%) and 13 female (31%). The mean age of females (41.96y) was less than males (52.16y). The most common reasons for referring for Enteroscopy was Melena with unknown source (8 cases, 19%) and abdominal pain (6 cases, 14.3%). More than half of the patients (28 cases, 67%) were nonsmoker. The most common findings of Enteroscopy include peptic ulcer disease (PUD) (12 cases, 28.6%), hemorrhage from angiectasia (11 cases, 26.2%), erosive gastritis (9 cases, 21.4%) and small bowel stenosis and atrophy (7 cases, 16.7%). Among the complications after Enteroscopy, only abdominal pain was reported (2 cases, 4.76%). Conclusion: balloon Enteroscopy is a safe procedure and useful for evaluation of source of obscure bleedings and pain of unknown origin.

Role of balloon enteroscopy for obscure gastrointestinal bleeding in those with surgically altered anatomy: A systematic review.

BACKGROUNDObscure gastrointestinal (GI) bleeding is defined as persistent bleeding despite negative evaluation with both esophagogastroduodenoscopy and colonoscopy and can be secondary to small intestinal pathology. Standard endoscopy as well as push endoscopy can be a challenge in those with altered anatomy given inaccessible areas as well as perforation risk. Single and double balloon enteroscopy can be warranted in this patient population in instances of obscure GI bleed. AIMTo assess the safety and diagnostic efficacy of balloon enteroscopy for obscure GI bleeding in patients with surgically altered anatomy. METHODSA search was conducted through PubMed, MEDLINE, Google Scholar, Scopus, and Embase with the key words “enteroscopy,” “obscure bleeding,” and “altered anatomy,” to identify relevant articles in English with no restricted time frame. A search within the Reference Citation Analysis database was conducted to ensure inclusion of the latest high impact articles. Study types included in the review were prospective and retrospective reviews, case series, and case reports. The reference lists of these papers were also reviewed to find further papers that were applicable. The authors extracted the data from the studies that fit inclusion criteria. Data of interest included type of study, type of procedure, and type of altered anatomy, as well as the number of patients with any diagnostic or therapeutic intervention. Data was also recorded on procedure tolerance and complications. The data was analyzed with descriptive statistics. RESULTSOur literature search yielded 14 studies that were included. There were 68 procedures performed with 61 unique patients subjected to these procedures. Forty-four (65%) of the procedures were double balloon, 21 (31%) were single balloon, and 3 (4%) were classified as through the scope balloon assisted. The most common altered anatomy types included Gastric Bypass Roux-en-Y, Pylorus Sparing Whipple, Orthotopic Liver Transplantation with Roux-en-Y, and Gastrojejunostomy Roux-en-Y. The procedures were successfully performed in each patient. There were 5 (7%) procedures that were complicated by perforation. Amongst the available data, the diagnostic yield was 48/59 (81%) and a therapeutic yield of 39/59 (66%). One patient was recommended surgical revision of their altered anatomy following enteroscopy.CONCLUSIONBalloon enteroscopy is a useful diagnostic modality in investigating obscure GI bleeding within those with surgically altered anatomy; however, precautions must be taken as this population may have increased perforation risk.

Usefulness of Intestinal Ultrasound to Detect Small Intestinal Stenosis in Patients With Crohn's Disease.

Double balloon enteroscopy (DBE) with retrograde contrast is useful as a monitoring tool for small intestinal lesions in Crohn's disease (CD), but these are burdensome for patients. Intestinal ultrasound (IUS) can be used with ease in daily clinical practice, but there is less evidence regarding the accuracy of detection of small intestinal stenosis in CD. This study aimed to examine the diagnostic power of IUS for small intestinal stenosis in patients with CD. The findings of DBE and IUS in 86 patients with CD with small intestinal lesions were evaluated. Using DBE as the reference standard, we examined the detection rate of IUS for small intestinal stenosis. We evaluated three parameters: luminal narrowing, prestenotic dilation, and to-and-fro movement for determining stenosis using IUS. In addition, we compared the characteristics between the stenosis-detectable and stenosis-undetectable groups by IUS. Of the 86 patients, 30 had small intestinal stenosis. In IUS findings, when lesions that met two or more of the three parameters were judged as stenosis, the detection rate was 70.0% for sensitivity, 98.2% for specificity, and 88.4% for accuracy. Moreover, there were patients with a younger age at diagnosis (P < 0.05) and more ileocolonic disease location (P < 0.05) in the stenosis-detectable group by IUS. The stenoses detected by IUS were significantly longer than those undetected by IUS (14.1 mm versus 5.2 mm, P < 0.05). IUS delivered reliable results for clinically important small intestinal stenosis of CD with high diagnostic accuracy.

Factors That Influence the Speed and Completion of Double Balloon Enteroscopy in Patients with Arteriovenous Malformations.

Double balloon enteroscopy remains a resource and time-intensive procedure that is not available in many endoscopy units. We aimed to identify variables impacting the speed and completion of double balloon enteroscopy. We retrospectively reviewed 550 patients. Using a mean time and distance for both the antegrade and retrograde approach, we determined the procedure speed and assessed factors that influenced it. In addition, we assessed the factors that contributed to a complete double balloon enteroscopy. A total of 386 antegrade and 164 retrograde double balloon enteroscopies were performed. Greater than 10 AVMs requiring treatment was a negative predictor (AOR 0.25, CI 0.11-0.51, p < 0.001), whereas age greater than 60years (AOR 2.66, CI 1.18-6.65, p = 0.025) was a positive predictor of a fast antegrade enteroscopy. For retrograde, prior abdominal surgery was the only factor that trended to significance (AOR 0.38, CI 0.14-0.99, p = 0.052). A total of 120 combined procedures were performed. Female gender (AOR 2.62, CI 1.16-6.24, p = 0.02), history of prior abdominal surgery (AOR 0.31, CI 0.13-0.70, p = 0.006) and Boston bowel pre-preparation score of greater than 6 (AOR 4.50, CI 1.59-14.30, p = 0.006) were the only significant predictors of a complete procedure. By applying double balloon enteroscopy speed, a novel method of measuring procedure efficiency, we were able to more reliably identify the factors that will negatively impact the speed and success of the procedure.

Single balloon enteroscopy revealed multiple (&gt;20) non-bleeding polypoid mucosal nodules with vascular ectasia approximately 5 to 10 mm in size beginning in the proximal jejunum. No active bleeding was appreciated.

Single balloon enteroscopy revealed multiple (&gt;20) non-bleeding polypoid mucosal nodules with vascular ectasia approximately 5 to 10 mm in size beginning in the proximal jejunum. No active bleeding was appreciated.

Diagnosis and treatment of diverticular hemorrhage in small intestine: A retrospective study

Background and study aimsSmall intestine diverticula are the most common cause of gastrointestinal hemorrhage, but prompt diagnosis remains challenging. Thus, this study aimed to identify strategies for the diagnosis and treatment of diverticular hemorrhage. Patients and methodsPatients who presented with gastrointestinal tract bleeding to Guangzhou First People's Hospital between 2008 and 2014 were retrospectively examined. Gastrorrhagia and colonic hemorrhage were excluded based on the gastroscopy and colonoscopy findings, and the bleeding sites were in the small intestine. Data regarding patient characteristics, methods of diagnosis, treatment, and prognosis were collected. ResultsEighty-five patients met the study criteria, and 45 patients were diagnosed with diverticular hemorrhage using double balloon enteroscopy, capsule endoscopy, computed tomography (CT), or digital subtraction angiography (DSA). Among these patients, 10 presented with massive bleeding and hemodynamic instability. All 45 patients underwent surgery and recovered with no complications, and all patients were followed-up for over 3 years, with no cases of recurrent hemorrhage. ConclusionDiverticular hemorrhage is the most common cause of small intestine bleeding. Double balloon enteroscopy, capsule endoscopy, CT, and DSA are effective methods for diagnosing small intestine diverticular hemorrhage. Surgical resection of the involved region is necessary and may achieve complete cure.

Intussusception of the third portion of the duodenum secondary to a primary duodenal malignancy: A case report.

Introduction and importanceIntussusception is invagination of the bowel and is rare in adults, representing only 5% of all cases of intussusception. Duodenal intussusception is also very rare. To the best of our knowledge, there is only one previous report of a malignant tumor in the fourth portion of the duodenum as the lead point of intussusception (Vaibhav et al., 2021 [1]). This reports a duodenal-duodenal intussusception caused by a malignant tumor in the third portion of the duodenum.Case presentationA 36-year-old woman with abdominal pain was diagnosed with duodenal intussusception by abdominal ultrasonography and computed tomography scan. Double balloon endoscopy showed that the intussusception had spontaneously reduced, and a tumor was found in the third portion of the duodenum. Open resection was performed because of the tumor location. Pathologic examination revealed adenocarcinoma with an adenoma of the duodenum. The patient had no evidence of recurrence for 4 years after resection.Clinical discussionThis patient had a primary duodenal malignancy and presented with intussusception, Duodenal intussusception is a rare condition requiring prompt intervention, usually requiring surgery. In this patient, since endoscopic resection was difficult, partial resection of duodenum was performed by open surgery assisted by double balloon enteroscopy. The pathological diagnosis of the resected specimen was primary duodenal malignancy.ConclusionThis is a report of adult duodenal intussusception caused by a primary duodenal malignancy. This rare condition posed an intriguing challenge for the optimal operative approach.

Jejunal Hemolymphangioma in a Patient Presenting with Gastrointestinal Bleeding

Background: Hemolymphangioma is rarely found in the small intestine. There have only been eight reports of hemolymphangiomas arising in the small intestine to date. The first patient was reported by Fang et al. in 2012. A small intestinal hemolymphangioma may lead to anemia and gastro-intestinal bleeding. Case Presentation: We report a case of jejunal hemolymphangioma in a 49-year-old man. The patient presented with melena and anemia. He underwent double balloon enteroscopy (DBE) the antegrade approach, which demonstrated a 3.0 cm segment of jejunum with nearly 75% of the circumferential lesion with blood remnant. The raised soft lesion was in the middle of the jejunum with white patches on the surface of the mucosa. Endoscopic biopsy was not performed to avoid secondary bleeding. The patient underwent laparotomy, and partial small intestine resection was performed. A 5.0cm segment of jejunum was resected with primary anastomosis. The patient had an uneventful postoperative recovery. Macroscopic pathological examination showed a cavernous, soft and compressible tumor. Microscopic examination showed a tumor which was composed of blood and lymphatic vessels mainly located in the submucosa. The definitive histological diagnosis was jejunal hemolymphangioma. During a follow-up of 2 years, there was no further gastrointestinal bleeding. Conclusion: Small intestinal hemolymphangioma is a rare benign tumor of which clinical manifesta-tions are nonspecific and accurate preoperative diagnosis is challenging. Endoscopic biopsy is not rec-ommended for hemolymphangioma of the gastrointestinal tract due to the risk of severe bleeding. Com-plete surgical resection of the hemolymphangioma is considered the most effective treatment for small intestinal hemolymphangioma.

Direct percutaneous endoscopic jejunostomy (DPEJ) and percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) technical success and outcomes: Systematic review and meta-analysis.

Background and study aims Endoscopic methods of delivering uninterrupted feeding to the jejunum include direct percutaneous endoscopic jejunostomy (DPEJ) or PEG with jejunal extension (PEG-J), validated from small individual studies. We aim to perform a meta-analysis to assess their effectiveness and safety in a variety of clinical scenarios. Methods Major databases were searched until June 2021. Efficacy outcomes included technical and clinical success, while safety outcomes included adverse events (AEs) and malfunction rates. We assessed heterogeneity using I 2 and classic fail-safe to assess bias. Results 29 studies included 1874 patients (983 males and 809 females); mean age of 60 ± 19 years. Pooled technical and clinical success rates with DPEJ were 86.6 % (CI, 82.1–90.1, I 2 73.1) and 96.9 % (CI, 95.0–98.0, I 2 12.7). The pooled incidence of malfunction, major and minor AEs with DPEJ were 11 %, 5 %, and 15 %. Pooled technical and clinical success for PEG-J were 94.4 % (CI, 85.5–97.9, I 2 33) and 98.7 % (CI, 95.5–99.6, I 2 < 0.001). The pooled incidence of malfunction, major and minor AEs with DPEJ were 24 %, 1 %, and 25 %. Device-assisted DPEJ performed better in altered gastrointestinal anatomy. First and second attempts were 87.6 % and 90.2 %. Conclusions DPEJ and PEG-J are safe and effective procedures placed with high fidelity with comparable outcomes. DPEJ was associated with fewer tube malfunction and failure rates; however, it is technically more complex and not standardized, while PEG-J had higher placement rates. The use of balloon enteroscopy was found to enhance DPEJ performance.